Residual Functional Capacity

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Gabriella Mathews
6 years ago
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1 Fatigue RFC Name: Claim #: Date of Injury: What is the first date at which your patient s impairment(s) became severe meaning that his Date: or her impairment(s) caused interference their ADL s or ability to work? When did you begin treating the patient? Date: How frequently do you see your patient? Date: Please answer the following questions concerning your patient's disorders and associated health problems. 1. Underlying diagnoses 2. Prognosis: [Exertional capacity addresses an individual's limitations and restrictions of physical strength and defines the individual's remaining ability to perform each of seven strength demands: Sitting, standing, walking, lifting, carrying, pushing, and pulling. An exertional limitation is an impairment-caused limitation of any one of these activities. Non-exertional capacity considers any work-related limitations and restrictions that are not exertional. Therefore, a non-exertional limitation is an impairment-caused limitation affecting such capacities as mental abilities, vision, hearing, speech, climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, fingering, and feeling. Environmental restrictions are also considered to be nonexertional. Thus, it is the nature of an individual's limitations and restrictions, not certain impairments or symptoms that determines whether the individual will be found to have only exertional limitations or restrictions, only non-exertional limitations or restrictions, or a combination of exertional and non-exertional limitations or restrictions. For example, even though mental impairments often affect non-exertional functions, they may also limit exertional capacity affecting one of the seven strength demands; e.g., from fatigue or hysterical paralysis. Likewise, symptoms, including pain, are not intrinsically exertional or non-exertional; when a symptom causes a limitation in one of the seven strength demands, the limitation must be considered exertional. (SSR: 96-9p)] Is there a reasonable medical probability that your patient: Will experience fatigue due to pain? Will experience fatigue due to depression? Will experience fatigue due to the side effects of medication? Will experience fatigue due to the underlying medical condition(s)? Will experience fatigue due to any other medical condition(s). Will experience fatigue due to the combination, or the synergistic effect, of multiple factors such as pain, depression, side effects of medication, if any, and the functional limitations of the underlying condition(s) Page 1 of 6

2 Will your patient experience fatigue due to hyper-somnolence resulting from any of the following symptoms and signs: (please check) Cataplexy Sinus arrhythmia Hypnogogic phenomenon Insomnia Extreme bradycardia Ventricular tachycardia Atrial flutter Sleep paralysis Excessive daytime sleepiness Cognitive problems Automatic behavior Hypercapnia Sleep apnea: A. Obstructive B. Central C. Mixed Other SIDE EFFECTS OF MEDICATION Is there a reasonable medical probability that claimant will experience side effects from medication(s)? What side effect(s) are likely to occur, if any? Sweating Dry Mouth Weight Loss Depression Drowsiness Feeling weak Difficulty maintaining concentration Dizziness Reduced short term memory Confusion Constipation Low Energy Mental/Mood Changes Headaches Blurry Vision Trouble Sleeping Nausea Loss of Appetite Other Vomiting Diarrhea Other Sedation Weight Gain Other Will the claimant experience fatigue due to the side effects from the medication? YES NO Please list medications for non-industrial condition(s), if any? Is there a reasonable medical probability the claimant will experience side effects from non-industrial medication(s), if any? Yes No If yes, please explain: In utilizing this form, please assume the following definitions: 1. Mild assumes an annoyance but no reduction in the ability to perform the function. 2. Severe assumes an inability to perform the function. 3. For the purpose of this section please assume that off task means an inability and/or a reduction in productivity over the course of a work day, 8 hours or otherwise. If appropriate, please choose one of the 4 following definitions of Moderate you feel best describes claimant s functional limitations taking into account the side effects of the medication(s), if any: 1. Will be off task up to 10% of the time in an 8 hour day; 2. Will be off task up to 15% of the time in an 8 hour day; 3. Will be off task up to 20% or more of the time in an 8 hour day; 4. Will be off task % of the time in an 8 hour day. To what degree will the side effects impair claimant s ability for concentration, persistence pace separate and apart from the underlying industrial medical condition(s)? To what degree will the side effects impair claimant s ability for concentration, persistence and pace in combination with the underlying industrial medical condition(s)? When side effects exist can you estimate the severity? Hours < Approximate duration of the most severe side effect(s): Page 2 of 6

3 Is claimant allowed to operate machinery or motorized vehicles when experiencing side effects from the medication? Is there a reasonable medical probability that the side effects will reduce claimant s ability to perform work to a minimum standard of productivity while working? If yes, to what degree: Is there a reasonable medical probability that the side effects will reduce claimant s ability to perform detailed work requiring hand/eye coordination? If yes, to what degree: Is there a reasonable medical probability that the side effects will reduce claimant s cognitive acuity and/or ability to focus on activities such as reading, writing, computer use? If yes, to what degree: Is there a reasonable medical probability claimant s fatigue, if any, due to the combined effects of his or her medical condition(s), will reduce his or her exertional capacity to sit, stand, walk, lift, carry, push and/or pull? REDUCED FUNCTIONALITY DUE TO FATIGUE: How many hours of a work day, 8 hours or otherwise, can claimant be expected to sustain competitive work: < Sit Stand Walk Drive EXERTIONAL PHYSICAL DEMANDS (LIFT, CARRY, PUSH AND PULL) LIFT < 10 pounds 10 pounds pounds pounds pounds < 10 pounds 10 pounds pounds pounds pounds < 10 pounds 10 pounds pounds pounds pounds Rarely Rarely Rarely CARRY PUSH/PULL Page 3 of 6

4 Will claimant need allowance to alternate positions at will? YES NO Comments: If claimant were placed in a competitive work situation, please estimate the number of minutes or hours claimant is able to sit, stand, or walk or drive at one time without interruption before needing to alternate positions. Estimated maximum duration of each activity: Capacity for: <5 min 5 min 10 min 15 min 20 min 30 min 45 min 1 hour without a break 2 hours without a break Sitting Walking Standing Driving If claimant must alternate positions after sitting, walking, standing, or driving the maximum duration estimated above, can you estimate of the length of time needed before claimant can resume sitting, walking, standing or driving? Break time: <1 min 5min 10min 15min Sitting Walking Standing Driving UNSCHEDULED BREAKS Is there a reasonable medical probability that claimant will need to take unscheduled breaks from work activity during the workday? If claimant needs to take unscheduled beaks to relive or control pain can you estimate how often and for how long he or she may have to do so? About minutes; every hour(s) LIE DOWN/RECLINE DUE TO FATIGUE Is there a reasonable medical probability that claimant will need to take lie down or recline from work activity during the workday due to fatigue? If claimant needs to lie down or recline to relive or control pain can you estimate for how often and how long may he or she have to do so? About minutes; every hour(s) If your patient was placed in a competitive job, identify those aspects of workplace stress that your patient would be unable to perform or be exposed to due to fatigue: Routine, repetitive tasks at consistent pace Detailed or complicated task Strict deadlines Fast paced tasks (e.g., production line) Exposure to work hazards (e.g., heights or moving machinery) If your patient experiences symptoms, including fatigue, that interfere with the attention and concentration needed to perform even simple work tasks, during a typical workday, please estimate the frequency of interference: Rare If your patient experiences symptoms, including mental or physical fatigue manifested in somnolence (decreased wakefulness) that interfere with the ability needed to perform even simple work tasks, during a typical workday, please estimate the frequency of interference: Rare Page 4 of 6

5 If your patient experiences symptoms, including mental or physical fatigue manifested in general decrease of attention, not necessarily including sleepiness that interfere with the ability needed to perform even simple work tasks, during a typical workday, please estimate the frequency of interference: Rare If your patient experiences symptoms, including excessive daytime sleepiness (EDS) characterized by persistent sleepiness, and often a general lack of energy and fatigue even after apparently adequate night time sleep that interfere with the ability needed to perform even simple work tasks, during a typical workday, please estimate the frequency of interference: Rare Will claimant s impairments likely to produce good days and bad days? If yes, please estimate, on average, how many days per month claimant is likely to be absent from work as a result of the impairments or treatment? Never About one day per month About two days per month Page 5 of 6 About three days per month About four days per month More than four days per month MENTAL ACTIVITIES THAT MAY BE ADVERSLY AFFECTED BY FATIGUE Each mental activity is to be evaluated within the context of the individual's capacity to sustain that activity over a normal workday and workweek, on an ongoing basis. Chapter 14.3e Class of Impairments Due to Mental and Behavioral Disorders 1. None means no impairment is noted in the functions. 2. Mild implies that any discerned impairment is compatible with most useful functioning. 3. Moderate means that the identified impairments are compatible with some, but not all, useful functioning. 4. Marked is a level of impairment that significantly impedes useful functioning. Taken alone, a marked impairment would not completely preclude functioning, but together with marked limitation in another class, it might limit useful functioning. 5. Extreme means that the impairment or limitation is not compatible with useful function. None Mild Moderate Marked Extreme Ability to perform tasks that require constant concentration, such as driving a vehicle to and from work. Ability to perform tasks that require constant concentration, such as operating machinery, equipment or electric operated tools. Ability to maintain concentration and attention for extended periods (the approximately 2-hour segments between arrival and first break, lunch, second break, and departure). Ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances. Ability to sustain an ordinary routine over an eight hour work day. Ability to be aware of normal hazards and take appropriate precautions. Ability to complete a normal workday and workweek without interruptions from fatigue and perform at a consistent pace without an unreasonable number and length of rest periods. The ability to carry out repetitive and prolonged activities. The ability to carry out detailed instructions.

6 I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the report accurately describes the information provided to me and except as noted herein, that I believe it to be true. I also declare under the perjury that this physician has no violated section of the Labor Code. My opinions are expressed to a degree of medical probability, unless otherwise stated. Signature of Physician Date Additional Comments: Page 6 of 6

1. Does your patient experience dizziness? Yes No 2. Does your patient experience seizures? Yes No

1. Does your patient experience dizziness? Yes No 2. Does your patient experience seizures? Yes No VERTIGO/SEIZURES RESIDUAL FUNCTIONAL CAPACITY Name: Claim #: Date of Injury: Please Print Name of Medical Evaluator: Medical Specialty: What is the first date claimant s impairment(s) became severe meaning